building resilience e szabo c., kelemano., & keri s. (2013) bol psychiatry lauren ashbaugh,...
TRANSCRIPT
BUILDING RESILIENCE
• February 21st, 2019
Lauren Ashbaugh, Ph.D., NCSP
AGENDA
8:35-8:45 Setting the stage
8:45-9:00 Defining resilience
9:00-9:20 ACEs, trauma, & toxic stress
9:20-9:30 Trauma & the body
9:30-10:00 Building resilienceContinua Consulting Group, LLCLauren Ashbaugh, Ph.D., NCSP
REFLECTION PAGE
• Find the numbers on the slides:
• Match the numbers to the questions on the reflection sheet.
• Voluntary and entirely for you.
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YOUR RIGHTS
• You have the right to take all the space you need. Please do. Some content is distressing.
• You have the right to choose how you prefer to participate.
• You have the right to use humor and laughter.
• You have the right to speak and be heard.
• You are invited to talk to me about any and all of this.
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• Do your best to be present.
• Do no harm.
• Be kind to yourself.
• Remember that vulnerability often leads to growth.
MY REQUESTS
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Chapter: SUDS: The Subjective Units of Distress Scale
From: Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE): Patient Workbook
www.anxietybc.com
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TENDING TO MY INTROVERTS .
Optional means optional
Feel free to choose to focus on empathy, listening, & reflection.
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EMPATHY: CLIMBING IN THE HOLE
BUILDING RESILIENCE
WHAT IS RESILIENCE?
Lauren Ashbaugh, Ph.D., NCSP
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AMAZING TACOMA KIDS2
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RESILIENCE
(1) the ability to face and cope with challenges;
(2) adapt to the changes created by these challenges; and
(3) recover and even grow from these setbacks.
Seelig et al. (2016) Sleep and health resilience metrics in a large military cohort.
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RESILIENT TO WHAT?
ACEs, Trauma, & Toxic Stress
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What are Adverse Childhood Experiences (ACEs)?
Source: Robert Wood Johnson Foundation
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HOW DID THE "ACES" STUDY ARISE?
Original question arose in 1985 in obesity clinic
Vincent Felitti, M.D.
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When he finished, one of the experts stood up and blasted him. “He told me I was naïve to believe my patients, that it was commonly understood by those more familiar with such matters that these patient statements were fabrications to provide a cover explanation for failed lives!”
Dr. Felitti at the North American Association for the Study of Obesity conference in 1990:
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Source: J.E. Stevens, Huffington Post, 10/2012
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THE ORIGINAL CDC/KAISER ACES STUDY*:
• Original question arose in 1985 in obesity clinic
• CDC partnered study spanned 1995-1997
• Kaiser Permanente in San Diego, CA
• 17,421 participants
Vincent Felitti, M.D.
Robert Anda, M.D., M.S.
Almost 2/3 had at least 1 ACE
40% had 2 or more ACEs
One in five had >3 ACEs
*Felitti & Anda et al, American Journal of Preventative Medicine, 1998
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Without intervention, 20 year difference in life expectancy with 4+ ACEs
Source: CDC
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CDC/KAISER ACES STUDY: WHAT’S MISSING?
• Peer victimization/bullying
• Deportation of family member
• Racism/institutional oppression
• Multiple deployments/military
• Caretaking an elderly or ill parent
• Acute health issue
• Car accident, health aftermath
• Natural disaster
• Multiple moves
• Losing a home/homelessness
• Loss of a colleague or teacher
• Poverty
• Disability
• Exposure to community violence
• Exposure to school violence
• Death of a family member
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ACEs in WASHINGTON SCHOOLS – SOPHOMORES AND SENIORS(2010)
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• Behavioral Risk Factor Surveillance System (BRFSS)
• Over 23 states, 200,000+ participants
• Higher frequency of ACEs reported in:
• Women, young adults vs. men, older adults
• Less than high school diploma vs. HS graduate
• Multiracial, Hispanic, black vs. white
• Bisexual, LGBTQ vs. heterosexual
THE 2018 JAMA PEDIATRICS* ACES STUDY:
Merreck et al, 2019 JAMA Pediatrics. Graphic: CDC
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ACES AND INTERSECTIONALITY
• Race
• Gender identity
• Sexual orientation
• Nationality
• Disability
• Available resources and support
Source: YW Boston
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Intersectionality, n.
The interconnected nature of social categorizations such as race, class,
and gender, regarded as creating overlapping and interdependent
systems of discrimination or disadvantage; a theoretical approach based
on such a premise.
(Oxford Dictionary)
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CHRONIC EXPOSURES
Rejection
Exclusion
Oppression
Threat
Neglect
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REVISIT THE ORIGINAL CDC/KAISER ACES STUDY:
• Original question arose in 1985 in obesity clinic
• CDC partnered study spanned 1995-1997
• Kaiser Permanente in San Diego, CA
• 17,421 mostly middle-class adult participants
• 80% white, 10% black, 10% Asian
• 74% college-educated
• Average age: 57
Vincent Feletti, M.D.
Robert Anda, M.D., M.S.
Almost 2/3 had at least 1 ACE
40% had 2 or more ACEs
One in five had >3 ACEs
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WHAT DOES THIS MEAN ABOUT OUR STAFF? OURSELVES?
ASSUME ACES
Are we walking the talk?
With ourselves?
With each other?
ASSUME SECONDARY TRAUMATIZATION/COMPASSION FATIGUE
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LANGUAGE
Toxic Stress
Adversity, Challenges, Setbacks
Chronic Trauma
Are we supporting a deficit model?
Are we underemphasizing resilience?
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WHY WAS THE ACES STUDY REVOLUTIONARY?WE DON’T LIKE TO SIT WITH TRAUMA
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EVIDENCE-BASEDTREATMENTS
FOR PTSD
Heal the wound
Enhance strengths
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HISTORICAL CONSEQUENCE OF AVOIDANCE
• Missed opportunities for intervention
• Misdiagnosis and misuse of funds
• Neglect of impact on society, community, individuals
• Erasing history to avoid responsibility, accountability
• Perpetuate shame, guilt, overresponsibility in survivors
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WE ARE ALONE WITH IT.
WE LEAVE OTHERS ALONE WITH IT.
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Toxic Stress & the Brain
• Overactive ”Fight, Flight, or Freeze” – amygdala changes
• Changes to reward system functioning and pleasure centers (VTA)
• Structural changes to executive functioning/prefrontal cortex
• Memory center: hippocampal neurotoxicity; reduced volume
Ulrich-Lai 2009, Roth 1988, Iperato1991, Charmandari2005, McEwen 2010, McEwen 2007, Bierhauset al. 2003; Kiecolt-Glaser et al. 2003
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Can result in:
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• inflammation
• Infection
• cardiovascular problems
• chronic diseases
Toxic Stress & the Body
Ulrich-Lai 2009, Roth 1988, Iperato1991, Charmandari2005, McEwen 2010, McEwen 2007, Bierhauset al. 2003; Kiecolt-Glaser et al. 2003
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• HPA axis & cortisol response
• Adrenaline
• Growth hormone/thyroid
• Pubertal hormones
• Levels of leptin and ghrelin
• satiety & appetite
Miller 2007
Increased risk of changes to:Increased risk of:
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• Epigenetic changes & impact
• Biological mechanisms that turn genes on and off
• Affected by what you eat, where you live, how you
sleep, exercise, aging, and by your experiences
Toxic Stress & the Body
Su 2014
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Toxic Stress & the Body
Childhood
Learning difficulties
Behavioral difficulties
Asthma & allergies
Infections
Atopic diseases
Pneumonia
Early Childhood
Developmental delay
Growth delay
Failure to thrive
Sleep disruption
Behavioral disruption
Adolescence
Learning difficulties
Behavioral difficulties
Obesity
Diabetes
Headache & abdominal pain
Hyperthyroidism
Pubertal changes
Adapted from: Burke-Harris 2018; Oh et al., in press, Matheson, 2016; Kerker 2015, Shen 2016, Ryan 2015, Giordano 2014, Rhodes 2012, Thompson 2017, Bjorkenstam 2015
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What does trauma look like in a classroom?
Arousal & Reactivity
Avoidance
Distorted thinking
Reexperiencing
Sleep disturbanceProblems concentrating
It’s not safe. I’m not safe. Gotta watch my back.
No way will I stay in that class.
(I could be embarrassed or fail again.)
I will fail if I try.
It happened because of me.
He sounds just like my stepdad.
I hate being yelled at.
I’m so tired. I can’t stay awake. I – I’m confused. Did we do this
yesterday?
I don’t know why I blew up like that
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Symptom PTSD Depression ADHD Anxiety ODD (Oppositional)
Anger/Irritability X X X
Difficulty concentrating X X X X
Recklessness/impulsivity X X X
Trouble sleeping X X X
Social problems X X X X X
Lack of interest X X
Difficulty relaxing X X
Agitation/Restlessness X X X X
Youth Mental Health and Symptom Overlap:
Is it really ADHD?
Lauren Ashbaugh, Ph.D., NCSP
TRIGGERS:
• Can be external (environment) reminders or internal (eg., thoughts)
• Can be reminders of the feelings related to the event(s)
• Guilt, shame, worthlessness, powerlessness
• Embarrassment, humiliation, rage
If the response seems to be much bigger than the situation
seems to call for, there is likely powerful historical context.
Lauren Ashbaugh, Ph.D., NCSP
We know that toxic stress changes the body.
Positive experiences do too.
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• General definition: The quality of being shaped or molded.
• Biology: The adaptability of an organism to changes in its environment or
differences between its various habitats.
• Neuroscience: The brain’s ability to change – for better or for worse
What is plasticity?
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Changing thoughts, changing body
12 week course of CBT for PTSD
• Statistical increase in hippocampal volume
• Significant increase in gene expression of FKBP5
• Significant improvement in PTSD symptoms
Levi-Gigi, E Szabo C., Keleman O., & Keri S. (2013) Bol Psychiatry
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NOW THAT WE KNOW, WHAT DO WE NEED?
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Between stimulus and response, there is a space.
In that space lies our freedom and our power to choose our response.
In our response lies our growth and our happiness.
-Steven R. Covey, summarizing Viktor Frankl’s work
RESEARCH ON RESILIENCE
1st wave: Inherent characteristics of the children that fared better than others
2nd wave: How resilience factors of children led to better outcomes
3rd wave:
How do we promote resilience through prevention, intervention, and policy change?
1. Traub, F & Boynton-Jarrett, R. 2017
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RESILIENCE
“Far from being inherent to the child, resilience
results from a complex interplay between the
child’s genetics, natural temperament, knowledge
and skills, past experiences, social supports, and
cultural and societal resources.”
- Traub, F & Boynton-Jarrett, R. 2017, emphasis mine
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TWO-PRONGS, SAME IDEA
Prevention
Reduce harm/exposures
Increase regulation & adaptive coping
Enhance positive identity formation, tenacity, competence
Increase connection and deepen meaningful relationships
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Prevention
Reduce harm/exposures
Increase regulation & adaptive coping
Enhance positive identity formation, tenacity, competence
Increase connection and deepen meaningful relationships
Sleep Mindfulness
Exercise Healthy Relationships
Nutrition Mental Health
EVIDENCE-BASED RESILIENCE BUILDING
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ANY DATA ON THOSE?
• Sleep: Rosenbaum, Vancamfort, & Steel et al (2015) Psychiatry Research
• Exercise: Ho, Chan, & Tang (2016). Psychiatry Research
Talbot, Maguen, & Metzler et al (2014) Sleep
• Nutrition: Clay (2017) Monitor on Psychology
• Mindfulness: Ortiz & Siibinga (2017) Children
• Healthy Relationships: Jaffe et al (2013) J of Adolescent Health
• Mental Health: Rolfsnes & Idsoe (2011) J of Traumatic Stress;
Kowalick et al (2011) J of Behavior Therapy and Experimental Psychiatry
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INCREASING SAFETY, REGULATION, CONNECTION
• Diet, exercise, sleep
education, access, advocacy, opportunity, parent engagement, health care
• Family health & engagement
connecting resources, increasing engagement, collaboration
• Social competence & belonging
SEL, culturally responsive, restorative practices, activities, leadership opportunities
• Executive functioning, locus of control, growth mindset, grit, optimism
PBIS; clear, consistent, predictable, rigorous content, high expectations
• Facing fears, reappraising experiences
counseling, mental health, cognitive therapy, graduated exposure, mindfulness
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Predictability
Consistent expectations
High expectations
Welcoming and warm
Engaging content and approach
Opportunities to start over
Avoiding power struggles
Opportunities for leadership
Co-Constructed Norms
Classroom community
Tier I: T-MTSS Principles
Arousal
Avoidance
Sudden, intense anger
Distorted thoughts
Concentration problems
Reexperiencing
Sleep problems
I can be safe here
I am valued here
I can be successful here
I am worth something
I matter to other people
Mistakes are learning
People believe in me.
Symptoms of trauma
I can trust other people
Why T-MTSS?
How does T-MTSS relate to a trauma-responsive school?
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MECHANISM: HEALTHY RELATIONSHIPS
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A SECURE, SUPPORTIVE RELATIONSHIP WITH AN ADULT
Dr. Emmy Werner
Hawaii: 700 people over 40 years – all the babies born on the island of Kauai in 1955 —from infancy through
adolescence and adulthood.
Werner found that one-third of the high-risk children grew into adults who were caring and successful.
“Having a secure, supportive relationship in early childhood is one of best predictors of whether you’d be resilient later in
childhood and into adulthood. If you had at least one relationship where people were able to do that soothing,
protecting…or help you build strength, if you had at least that one relationship at least that could protect you from many
other stress exposures.”
Lauren Ashbaugh, Ph.D., NCSP
A trauma-informed practice requires us to respond neutrally or constructively.
How do we increase reflection, compassion, and curiosity?
A SECURE, SUPPORTIVE RELATIONSHIP WITH AN ADULT
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WORKING TOWARDS A TRAUMA-INFORMED SYSTEM
Key principles of a trauma-informed approach:
1. Safety (physical and emotional)
2. Trustworthiness and transparency
3. Peer support
4. Collaboration and mutuality
5. Empowerment, voice, and choice
6. Recognition of historical and ongoing systematic traumatization
Source: SAMHSA, 2018Lauren Ashbaugh, Ph.D., NCSP
Lauren Ashbaugh, Ph.D., NCSP
Anticipate needs and create safe environments
Maintain composure in the face of fear and uncertainty
Respond to crises without personalizing, becoming defensive, or panicking
Perform to the best of our ability when we are needed most
Lean on and build the strengths of others; empower and support
What do we need from our pilot and flight crew?
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“We all carry within us places of exile, our crimes, our
ravages. Our task is not to unleash them on the world;
it is to transform them in ourselves and others.”
― Albert Camus
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ATTENDING TO YOURSELF IS TAKING CARE OF THEM.
• Kids respond to our emotions and reactions.
• Kids know when adults are lying or are inauthentic.
• We need to model what we want to see in them.
• We need to be able to problem-solve with peers for their benefit.
What are you most afraid of in your building/office/classroom?
Who do you go to for help? How safe does it feel to ask for help?
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IT’S A MINDSET, AND PRACTICES ARISE FROM MINDSET
• Students (and staff) want to do well.
• Something (skills deficit, crisis) may be getting in their way.
• Students and staff have tremendous potential and strengths. Build up both.
• Behavior has meaning and function. Look for both.
• Value the person, address the behavior
• Asking for help is a sign of strength and reflectiveness.
• Everyone needs help and connection.
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UNIQUE
https://changingmindsnow.org/
INSPIRATIONS
Laura van Dernoot Lipsky, MSW Rachel Lloyd, MA
Mary Oliver , Ph.D. Viktor Frankl, MD, Ph.D.
Jackson Katz, Ph.D. Patricia Resick, Ph.D.
Nadine Burke-Harris, MD, MPH
Robert Waldinger, MD Audre Lorde, MLS
Documentary: The Mask You Live In Documentary: Miss Representation
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